Generic Vicodin Easiest Opioid to Prescribe

It's a little-known fact: the combination drug hydrocodone/acetaminophen (Vicodin) is one of the easiest-to-prescribe opioids around. And that situation engenders much discussion among pain management specialists.

Almost all opiates fall under the Drug Enforcement Administration's strictest categories of controlled substances.

Heroin, for instance, is a Schedule I drug, while morphine, codeine, oxycodone, and other prescription opioids are just a step below, in Schedule II.

But generic Vicodin, the nation's most widely filled prescription according to an IMS Health report earlier this week, is one of a very few opiates listed under the less restrictive Schedule III, a group largely comprised of anesthetics and anabolic steroids.

That's part of the reason the drug is so commonly prescribed, according to researchers contacted by MedPage Today and ABC News. Many states have prescribing regulations linked to DEA scheduling, says Andrew Kolodny, MD, chair of psychiatry at Maimonides Medical Center in Brooklyn. Thus, it tends to be easier to write scrips for generic Vicodin than for any other opioid painkiller, including generic oxycodone products -- even combination ones like Percocet -- which fall under Schedule II.

A prescription for generic Vicodin can even be called in over the phone.

"But it is no less abusable or addictive than oxycodone or heroin," Kolodny says.

Hydrocodone alone is a Schedule II drug, but it almost always appears in combination with acetaminophen, under common brand names such as Vicodin, Lortab, and Norco.

Eugene Viscusi, MD, director of anesthesiology at Thomas Jefferson University in Philadelphia, says the DEA put the drug in a lower class was because it rationalized that no one would want to use too much and risk liver injury, an established side effect of acetaminophen.

"Guess again," Viscusi says.

While there are no solid figures on abuse of specific opioids, researchers say anecdotally that generic Vicodin accounts for a large part of prescription painkiller abuse -- although long-acting opioids, particularly extended-release oxycodone (OxyContin), have been largely blamed for the nation's addiction woes because they contain more drug.

Viscusi says that many physicians and prescribers still believe that hydrocodone is less potent and less addictive than other opioids. They also perceive that they won't be scrutinized by DEA and other state regulatory agencies for prescribing the lower-schedule drug, according to Michael Clark, MD, director of pain treatment at Johns Hopkins.

Clark says the high prescribing rate for generic Vicodin is also a symptom of a larger, "decades-long" push to recognize that pain was undertreated -- an effort that he says began with opioids for cancer pain and pushed into chronic, non-cancer pain, largely under the influence of drug makers.

"As access to these medications grew, so did misuse, abuse, and addiction, as well as their diversion," he said.

Now the federal government is trying to deal with the aftermath. During a widely publicized briefing earlier this week, the Obama administration announced its plan to curb prescription painkiller abuse, which it has dubbed an "epidemic."

Indeed, overdose deaths from prescription painkillers have surpassed those due to cocaine and heroin combined, and overall drug overdose deaths -- driven largely by these opioids -- have even surpassed car crashes as the top accidental killer in some states.

As part of the administration's push, the FDA announced a risk mitigation strategy to rein in extended-release and long-acting opioids like OxyContin and extended-release hydromorphone (Exalgo).

The strategy was widely criticized -- not least because it doesn't cover short-acting formulations such as generic Vicodin.

The only other opiates classified as Schedule III are codeine combination products such as Tylenol III (regular codeine is Schedule II), the addiction treatment buprenorphine (Suboxone), and a few others that physicians rarely use, or barely recognize.

Kolodny spearheads the doctor organization Physicians for Responsible Opioid Prescribing, or PROP; he says the group believes a schedule change is in order.

When PROP meets with national drug czar Gil Kerlikowske in early May, Kolodny says, "Rescheduling of hydrocodone combo products from III to II is on our agenda."

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